"Medicine is a social science, and politics is nothing else but medicine on a large scale"—Rudolf Virchow

August 25, 2018

News usually dries up on weekends, which gives me a chance to step back and get a little perspective on events in the DR Congo's tenth Ebola outbreak. Here's the Ministry of Health's table from four weeks ago, Saturday, August 4:

And here's today's table:

Some of the changes are dramatic: From 13 confirmed cases to 79, from three confirmed deaths to 42. But I read that positively: the MOH is doing a remarkable job of testing suspected cases under difficult circumstances. As well, some communities like Museniene seen little or no change in their numbers. It's also encouraging that the MOH hasn't yet run into any new cases that weren't known contacts of known cases. That was what was maddening about West Africa—someone would turn up with Ebola far from other cases, and contact tracing was a very hard, slow job.

So despite the growing numbers, I'm so far encouraged. As long as you can keep count of the cases, you're OK. It's also a good sign that the MOH is posting its daily updates right around 11:00 p.m. or midnight local time, and firing off an email about it to subscribers. If only Saudi Arabia were that much on top of events!

Still, I wish the Congolese were telling us more: about the communities, about the relationships between cases, about the staff working in the ETCs (who are among the bravest healthcare workers in the world). And about the lessons learned. It may seem like a dubious distinction, but the Congolese are becoming world experts in the handling of viral hemorrhagic disease outbreaks. Those outbreaks won't always be confined to the DR Congo, or to Africa, and other healthcare systems should be taking copious notes.

I also wish the Congolese media were doing more. Too often, their online sites are just rehashing yesterday's MOH update, or some Reuters report, rather than doing any serious reporting on their own. I realize that the DR Congo ranks 154th out of 190 nations on the 2018 Press Freedom Index, and that the country is overrun with trigger-happy militias like the Allied Democratic Forces in North Kivu. Still, it would be helpful if DR Congo reporters could interview healthcare workers, or Ebola survivors, or even ordinary people in the street, and publish what they learn.

On balance, though, the tenth outbreak is growing much more slowly than we might have expected, and the response has been faster and more effective. Let's hope we can say the same four weeks from now.

HILO >> East Hawaii on Friday endured a third day of epic rainfall from what was Hurricane Lane, flooding highways, severing power to homes across Hawaii island and overwhelming three sewage pump stations around Hilo Bay, triggering raw sewage spills at all three sites.

Dozens of residents in the Hilo neighborhoods of Piihonua and Reed’s Island had to be evacuated Thursday night as rushing flood- waters rose to alarming levels, prompting calls for assistance from both residents and tourists.

Mayor Harry Kim expressed frustration with the sluggish progress of the storm, which had slowed to 5 mph or less Friday as it passed west of Hawaii island. The slow crawl gave the storm system more time to dump rain on an already saturated island.

“East side, I don’t want any more rescues,” Kim said Friday. “Everybody just stay home, OK?”

Flooding of the upscale Reed’s Island neighborhood in Hilo prompted the evacuation of about 40 people and closed an array of roads across East Hawaii as the plodding storm dumped enormous amounts of rain on windward portions of the island.

Measurements of the thumping rainfall in East Hawaii show that Hakalau had a deluge of 33.7 inches of rain during the 48 hours ending at 10 a.m. Friday.

Data from the National Weather Service show Hilo airport saw 19.95 inches of rainfall over the same 48-hour period, while a rain gauge at Waiakea Experimental station outside of Hilo recorded 28.44 inches from Wednesday morning to Friday morning. A rain gauge at Honokaa recorded 29.28 inches of rainfall.

Two more people were diagnosed with dengue fever on Saturday, bringing the total number of people in Hong Kong who have contracted the mosquito-borne virus locally to 26 this year, the health authorities said.

The latest updates meant nine of the local cases either live on or had visited the island of Cheung Chau, while the remaining 17 had gone to the popular Lion Rock Park or Wong Tai Sin, the district where the park is located, since the first case was reported on August 14.

A 39-year-old woman who lives on Sai Wan Road on the island is one of the newly confirmed cases of the mosquito-borne disease. She works as a cleaner at Salesian Retreat House on Cheung Chau, and recalled being bitten by mosquitoes at her workplace and home.

She started to develop symptoms such as a fever and headache on August 17 and first sought medical care on August 21. As of Saturday, she was still being hospitalised at Pamela Youde Nethersole Eastern Hospital in Chai Wan and was in stable condition.

The woman’s two-year-old son had a fever and cough but has recovered. Others at home, including her husband and a daughter, did not present any symptoms.

Another identified sufferer was a 40-year-old Hong Kong man who lives at Charming Garden in Mong Kok. During the incubation period – the moment of exposure to the virus to the time symptoms appear – he visited Cheung Chau and Shenzhen, a neighbouring mainland city. The man works as a part-time construction worker in Tiu Keng Leng and went to Queen Mary Hospital for medical care on Friday. He was also in stable condition.

Centre for Health Protection controller Dr Wong Ka-hing on Saturday described the current local outbreak of dengue fever as “very quick” and “unprecedented”.

“The development [of the disease] on Cheung Chau is more worrying and not easy to predict,” Wong said. “We expect there will be new cases in the near future.”

Undersecretary for Food and Health Dr Chui Tak-yi said hygiene officers would visit parts of the island less frequented by people to carry out mosquito control measures.

The epidemiological situation of the Ebola Virus Disease dated August 24, 2018:

• A total of 107 cases of haemorrhagic fever were reported in the region, 79 confirmed and 28 probable.

• Of the 79 confirmed cases, 14 are cured, 23 are hospitalized and 42 have died.

• 6 suspected cases are under investigation.

• 2 new confirmed cases, including 1 in Mabalako and 1 in Oicha. All are known and followed contacts.

• 3 new people healed, including 2 in Mabalako and 1 in Beni.

• 3 deaths from confirmed cases in Mabalako.

Remarks:

To avoid that the total number of cases varies (up or down) daily, the suspect cases have been placed in a separate category. Thus, suspect cases with positive laboratory tests will be added to the confirmed category, while negative ones (non-cases) will be removed from the table.

The category of probable cases includes all reported deaths for which it was not possible to obtain biological samples for laboratory confirmation. The investigations will determine whether these deaths are related to the epidemic or not.

News of the response

Water, hygiene and sanitation

• A health team disinfected and closed a clinic in Beni health zone after it reported 3 cases, including 2 confirmed and 1 probable. The Water, Hygiene and Sanitation (WASH) Commission and Biosafety is the commission responsible for measures to stop the transmission of infectious diseases to other people and health workers. Thus, it deals in particular with the distribution of personal protective equipment to health workers, the installation of chlorinated water points and the disinfection of households and health facilities.

Vaccination

Since vaccination began on August 8, 2018, 3,481 people have been vaccinated , including 1,712 in Mabalako, 761 in Beni, 887 in Mandima and 121 in Oicha.

On 14 August 2018, the World Health Organization (WHO) received information from the WHO Regional Office for Europe about a confirmed yellow fever case in French Guiana. On 10 August 2018, the French National Reference Centre for arboviruses (Institut Pasteur de la Guyane) reported an autochthonous (locally acquired) laboratory confirmed case of yellow fever in an unvaccinated 47-year-old Swiss man in French Guiana.

Since April 2018, the case patient has lived in a forest area in the commune of Roura in French Guiana. On 4 August 2018, he developed flu-like symptoms, and on 8 August 2018 he was hospitalized in Cayenne, French Guiana, with fulminant hepatitis. On 9 August 2018, he was transferred to Paris, France where he received a liver transplant.

Epidemiological and entomological investigations have been conducted and no additional cases have been identified in the area of the patient’s accommodation. During contract tracing it was revealed that contacts of the case-patient did not report any unusual non-human primate mortality.

A reverse transcription polymerase chain reaction (RT-PCR) test was conducted at the French National Reference Centre and was positive for yellow fever.

Public health response

French Guiana health authorities are implementing several public health measures:

• Vector control measures have been strengthened around the risk zone (accommodation, health care facilities and airport).

• Information has been disseminated to health care workers to raise awareness about yellow fever.

• Messages on prevention measures for yellow fever are being disseminated in French Guiana through mass media campaigns (press release, radio) for local awareness and the promotion of vaccination.

Since the last Disease Outbreak News on 17 August 2018, 25 additional cases have been laboratory confirmed for Ebola virus disease (EVD) in the Democratic Republic of the Congo. These new confirmed cases have been reported in Beni, Oicha and Mabalako health zones (North Kivu province) and Mandima health zone (Ituri Province). However, all exposures and transmission events, to date, have been linked back to the outbreak epi-centre, Mabalako. Beyond the EVD outbreak, the Democratic Republic of the Congo is in a complex humanitarian crisis and is experiencing several other concurrent epidemics.

As of 22 August 2018, a total of 103 EVD cases (76 confirmed and 27 probable) including 63 deaths (36 confirmed and 27 probable) have been reported in five health zones in North Kivu (Beni, Butembo, Oicha, Mabalako, Musienene) and one health zone in Ituri (Mandima) (Figure 1). The majority of cases (62 confirmed and 21 probable) have been reported from Mabalako in Mabalako Health Zone (Figure 2). As of 22 August, six new suspected cases from Mabalako (n=3) and Beni (n=3) are pending laboratory testing to confirm or exclude EVD. A total of 88 confirmed and probable cases have age and sex reported. As of 19 August, the median age was 32 years (age range: 0-74), with the age group 30-39 accounting for 28% (25/88) of cases. Fifty eight percent (51/88) of all cases were female (Figure 3).

Fourteen cases have been reported among health workers, of which 13 were laboratory confirmed; one has died. Many of these health care workers were likely infected in clinics before the declaration of the outbreak, not in Ebola treatment centres (ETCs). WHO and partners are working with health workers and communities to increase awareness on infection, prevention and control (IPC) measures, as well as vaccinate those at risk of infection.

The MoH, WHO and partners continue to systematically monitor and rapidly investigate all alerts in all provinces of the Democratic Republic of Congo, and in neighbouring countries. Alerts in several provinces of the Democratic Republic of Congo as well as in Uganda, Rwanda, and the Central African Republic have been investigated; EVD has been ruled out in all alert events to date.

The ash falls were so heavy that trees broke under the weight, the RVO said in an information bulletin.

"The most affected areas are Baliau and Kuluguma and due to the very poor visibility caused by the ash fall, people are using torch light to move around," it said.

The RVO's Steve Saunders said it was an unusually large eruption.

"There are no casualties as far as we know but we are telling people to keep away from valleys for risk of mud flows ... there's a heavy thick blanket of ash on the flank and if there is heavy rainfall, we are making people aware of the threat," he said by phone.

Saunders said the initial phase of the eruption was over but a new vent had opened, indicating more activity may be likely.

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China, home to the world’s largest pig herd, has reported a fourth outbreak of the deadly African swine fever on Thursday, with worries growing about its rapid spread.

More than 400 pigs have been infected and the disease has now entered Zhejiang province, more than 2,000km from where it was first reported.

The infection has killed 340 hogs on three farms in Wenzhou, in eastern Zhejiang province, the Ministry of Agriculture and Rural Affairs said in a statement.

Wenzhou is a 2,150km (1,335 mile) drive south from Shenyang, capital of northeastern Liaoning province, where the first case was reported. It is the furthest site from the original infection so far reported.

The road from Shenyang to Wenzhou travels through the pig producing provinces of Hebei and Shandong, as well as Jiangsu, another infected region.

The third infection, detected at the weekend, was just 890km to the north in another coastal city, Lianyungang. There have also been cases inland in central Henan province.

This may stoke concerns that the disease is being transmitted along busy trade routes that take pigs from markets and farms in the northeast to slaughter and processing in the south. Some farmers have called for a nationwide ban on transporting live pigs.

Authorities have already culled more than 20,000 animals in an attempt to halt the spread of the highly contagious disease, which was first reported in China just three weeks ago.

But the vast distance between the new cases and the original outbreak will escalate worries about how to control the disease across China’s vast hog herd.

The rapid expansion of pig farms in recent years in China’s north-eastern cornbelt has increased the number of pigs being moved across country.

Local authorities in Wenzhou have banned the movement of live hogs, related products, and animals that are easily infected in to and outside the affected area, the ministry said.

Mike Coston at Avian Flu Diary has been following this story with some excellent posts.

Indigenous communities have been hit by measles. According the latest epidemiological bulletin from the Pan American Health Organization on August 20, Delta Amacuro state has the highest incidence of the disease and has recorded a total of 53 deaths, all of them of the Warao indigenous group.

The regional agency says in the bulletin that the measles epidemic "continues to be active, with transmission in all the states" of Venezuela, including the Capital District. It added that from the confirmation of the first case in min-2017 to August 2018, the government has recorded 4,272 cases and 62 deaths.

"The highest incidence of cases is reported in Delta Amacuro, with a rate of 66.5 per 100,000, followed by the Capital District with 47.0 per 100,000, Vargas with 12.4 per 100,000, and Miranda with 8.4," the bulletin says.